Research and analysis

Annex A: governance

Updated 9 December 2021

Applies to England

1. Background

NHS Health Checks are an important component of locally led public health prevention services. They are offered to people without pre-existing disease aged between 40 and 74, free of charge, every 5 years. The results are used to raise awareness and support individuals to make behaviour changes and, where appropriate, access clinical management to help them reduce their risk of a heart attack, diabetes, stroke, respiratory disease and some forms of dementia and cancer in the next 10 years.

The government’s prevention green paper Advancing our Health: Prevention in the 2020s recognised that the NHS Health Check programme, originally introduced in April 2009, has achieved a lot and continues to do so. A national evaluation of the programme (PDF, 1MB) estimates that at current statin prescribing levels, over 5 years, 2,500 people will have avoided a major cardiovascular event, such as heart attack or stroke.

In their current form, checks also underpin important NHS Long Term Plan commitments to prevent 150,000 heart attacks, strokes and cases of dementia, and are the major conduit for recruitment to the Diabetes Prevention Programme.

However, the green paper also recognised significant variation in uptake and follow-up of health risks identified by the programme, along with the potential that people could benefit from a more tailored service or a particular focus at pivotal changes in the life course. The government therefore announced its intention, building on the gains made over the past 10 years, to consider whether changes to the NHS Health Check programme could help it deliver even greater benefits.

To achieve this, the Department of Health and Social Care (DHSC) commissioned Public Health England (PHE) to undertake an evidence-based review of how NHS Health Checks can evolve in the next decade to maximise the future benefits of the programme. Professor John Deanfield, was appointed to chair the PHE review of the programme. The review work was completed by PHE in September 2021. On 1 October 2021, responsibility for national oversight of the NHS Health Check programme and for publishing the findings of the review transitioned to the Office for Health Improvement and Disparities (OHID).

This annexe to the report ‘Preventing illness and improving health for all: a review of the NHS Health Check programme and recommendations’ describes the governance arrangements for the review.

2. The steering group

Purpose

A steering group was established to provide strategic direction for the review, in line with the review terms of reference.

Meeting schedule

Thirteen meetings were held virtually over the course of the review. The secretariat was provided by PHE. The agenda and meeting papers were usually circulated a week before the meeting.

Confidentiality

Members of the steering group were asked not to disclose any information shared in the meeting if they thought it may have an impact on another member of the group or adversely affect the review work. While the meetings were not confidential, frank discussion and the sharing of views were encouraged in order to enhance the work. It was recognised that candour can be inhibited if members feel comments will be publicly attributed to them out of context. It was agreed that at times specific information, that is confidential, may be shared among the group and the confidentiality would be made explicit.

Declarations of interest

Each member of the steering group was asked to complete a declaration of interest form.

Membership

Professor John Deanfield, External Chair of the NHS Health Check review

Dr Alf Collins, Clinical Director, Personalised Care Group, NHS England and Improvement

Dr Charles Alessi, Senior Advisor, Public Health England

Professor Helen Stokes-Lampard, Chair, Academy of all Medical Royal Colleges and Faculties

Professor John Bell, Regius Professor of Medicine, University of Oxford; and Programme Leader for Accelerating Detection of Disease programme

Professor John Newton, Director of Health Improvement, Public Health England

Paul Ogden, Senior Advisor, Local Government Association

Dr Simon Eccles, Chief Clinical Information Officer for Health and Care, NHS England; and Deputy Chief Executive NHSX

Andrew Scott-Clarke, Director of Public Health, Kent County Council

Jim McManus, Director of Public Health, Hertfordshire County Council and Interim President of the Association of Directors of Public Health

3. Expert panel

An expert panel was established to advise on the work of the review.

Purpose

Members of the expert panel were invited to contribute to the success of the review by:

• informing the approach and providing support for the review as a whole
• providing scientific and clinical advice
• commenting on draft versions of the written report
• advising on the quality, limitations and appropriate use of evidence
• highlighting relevant practice and implementation issues relevant to the review and signposting the review team to further information on such issues
• assisting in the development of PHE’s recommendations, ensuring they are realistic and based on the strongest interpretation of findings from the review

Members can expect PHE to:

• give them reasonable time to provide feedback
• alert them to potential risks and issues that could impact the review, as they arise

Meeting schedule

Four meetings were held virtually over the course of the review. The secretariat was provided by PHE. The agenda and meeting papers were usually circulated a week before the meeting.

Confidentiality

Members of the expert panel were asked not to disclose any information shared in the meeting if they thought it may have an impact on another member of the group or adversely affect the review work. While the meetings were not confidential, frank discussion and the sharing of views were encouraged in order to enhance the work. It was recognised that candour can be inhibited if members feel comments will be publicly attributed to them out of context. It was agreed that at times specific information, that is confidential, may be shared among the group and the confidentiality would be made explicit.

Declarations of interest

Each member of the expert panel was asked to complete a declaration of interest form.

Membership

Chair: Professor John Newton, Director of Health Improvement, PHE, and member of the steering group for the review

Dr Shahed Ahmad, National Clinical Director for cardiovascular disease (CVD) prevention, NHS England and NHS Improvement

Professor Clive Ballard, Pro Vice Chancellor and Executive Dean, University of Exeter Medical School

Professor Brian Ference, Director of Research in Translational Therapeutics, University of Cambridge

Professor Carol Jagger, Professor of Epidemiology of Ageing, Newcastle University

Dr Matt Kearney, Director Primary Care Innovation and Deputy Managing Director, UCL Partners, Academic Health Science Network

Professor Nick Linker, National Clinical Director for Heart Disease, NHS England and NHS Improvement

Professor Anne Mackie, Director of Screening, PHE

Professor Tom Marshall, Professor of Public Health and Primary Care, University of Birmingham

Professor Dame Theresa Marteau DBE, Director of the Behaviour and Health Research Unit, University of Cambridge

Professor Rosalind Raine, Professor of Health Care Evaluation, UCL Institute of Epidemiology and Health Care

Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity, NHS England

4. Expert panel meeting minutes

First meeting: 19 October 2020, 11am to 1pm, Microsoft Teams

Attendees

Members:

• Professor John Newton, Chair and Director of Health Improvement, PHE

• Professor Clive Ballard, Pro-Chancellor and Executive Dean, College of Medicine and Health, University of Exeter

• Professor Brian Ference, Director of Research in Translational Therapeutics, University of Cambridge

• Professor Carol Jagger, Professor of Epidemiology of Ageing, University of Newcastle

• Professor Nick Linker, National Clinical Director for Heart Disease, PHE

• Professor Anne Mackie, Director of Screening, PHE

• Professor Tom Marshall, Professor of Public Health and Primary Care, University of Birmingham

• Professor Dame Theresa Marteau DBE, Director of the Behaviour and Health Research Unit, University of Cambridge

• Professor Rosalind Raine, Professor of Health Care Evaluation, UCL Institute of Epidemiology and Health Care

• Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity, NHS England

Presentation:

• Catherine Lagord: Senior Programme Analyst, PHE

• Katherine Thompson: Head of Programme, CVD Prevention, PHE

• Attendees: secretariat

• Clare Perkins, Deputy Director, Priorities and Programmes, PHE

• Ralph Mold, Senior Team Leader, review of the NHS Health Check programme, PHE

Apologies: Dr Matt Kearney, Director Primary Care Innovation and Deputy Managing Director, UCL Partners, Academic Health Science Network

Agenda item 1: welcome and introductions

1. The Chair welcomed everyone to the first meeting of the Expert Panel for PHE’s Review of the NHS Health Check and, gave an overview of the background and purpose of the review. This is followed by round of introductions.

2. The panel has been set up to advise the review on the evidence, the consideration of findings and the formation of recommendations arising from the review. The panel’s discussion will be summarised in the minutes, which will be publicly available. The panel will also review the final report and feedback their comments to the steering group ahead of final submission.

Agenda item 2: background to the review

3. Clare Perkins presented on the background to the review. The panel agreed that for the NHS Health Check programme to be effective in its aims it needs to provide a robust approach to both preventing ill-health and supporting the management of non-communicable diseases.

Agenda item 3: terms of reference

4. Ralph Mold presented the terms of reference for the expert panel, which the members agreed.

Agenda item 4: what do we know about the impact of the current NHS Health Check?

5. Katherine Thompson and Catherine Lagord gave a presentation on the data available on the current NHS Health Check and the findings that can be drawn from this relating to the impact of the programme.

6. The panel agreed that is important for any changes to the NHS Health Check programme to be evaluated thoroughly and on an ongoing basis. It was suggested that cluster randomised studies are a potential method of evaluation. The importance of ensuring that any methodology is able to evaluate any expected long-term benefits was noted.

7. It was suggested that the status quo – the current NHS Health Check – could provide the null hypothesis, or baseline, against which any proposals for a future programme could be compared.

8. The panel agreed that the impact of the NHS Health Check programme is likely to be influenced by the wider context of policy on health and prevention and this should be highlighted in the report. The existence and implementation of a broader strategy on prevention of ill-health may make individuals more receptive to behaviour change to reduce their risk or mean that there is more support available to enable them to do so. Additionally, there is a possibility that health professionals may be more likely to encourage behavioural change when they know follow-up services are available.

9. The panel discussed the implications of lowering the lower age-bound for the programme from 40. It was noted that starting earlier should bring about greater benefits in quality adjusted life years (QALYs) by prompting earlier action to reduce the risk factors for ill-health. However, it would be expected that this would be at a greater cost per QALY. The scale of additional benefits would depend on how far behavioural changes in younger people continue and accrue benefits over time, and how far they attenuate, reducing the overall benefits which accrue.

10. The panel discussed the potential for expanding the content of the NHS Health Check to address additional conditions. Cognitive impairment, mental health conditions, hearing loss and musculoskeletal conditions were all raised as worthy of consideration.

Any other business

11. Ralph Mold shared the 9 key questions the review is considering. The panel agreed that, as well as these questions, it was important to understand the impact of the existing programme.

12. The panel agreed that the question of how far the NHS Health Check programme should take additional action to focus on particular groups is important in considering the potential impact of the programme on health inequalities.

13. The next 2 meetings of the group will be on 12 November 2020 and 9 December 2020.

Second meeting: 12 November 2020, 12pm to 2pm, Microsoft Teams

Attendees

Members:

• Professor John Newton, Chair and Director of Health Improvement, PHE
• Professor Clive Ballard, Pro-Chancellor and Executive Dean, College of Medicine and Health, University of Exeter
• Professor Brian Ference, Director of Research in Translational Therapeutics, University of Cambridge
• Professor Nick Linker, National Clinical Director for Heart Disease, NHS England and Improvement
• Professor Tom Marshall, Professor of Public Health and Primary Care, University of Birmingham
• Professor Dame Theresa Marteau DBE, Director of the Behaviour and Health Research Unit, University of Cambridge
• Professor Rosalind Raine, Professor of Health Care Evaluation, UCL Institute of Epidemiology and Health Care

Secretariat:

• Clare Perkins, Deputy Director, Priorities and Programmes, PHE
• Ralph Mold, Senior Team Leader, Review of the NHS Health Check Programme, PHE
• Katherine Thompson, Head of Programme, CVD Prevention, PHE

Apologies:

• Dr Matt Kearney, Director Primary Care Innovation and Deputy Managing Director, UCL Partners, Academic
• Health Science Network
• Professor Carol Jagger, Professor of Epidemiology of Ageing, University of Newcastle
• Dr Shahed Ahmad, NHS England and Improvement
• Professor Anne Mackie, Director of Screening, PHE (represented by Dr Robert Sheriff)
• Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity, NHS England and Improvement

Agenda item 1: welcome and Introductions

1. The Chair welcomed everyone to the meeting and thanked members for a fruitful first meeting. The Chair explained that the purpose of this meeting is to consider the key questions of the review and the evidence the review team have identified so far to help in answering them. The next meeting will be devoted to discussing the evidence and potential recommendations.

Agenda item 2: minutes of the last meeting

2. The minutes were agreed, subject to amending paragraph 11 (any other business) to more fully reflect the panel’s discussion on the importance of understanding the impact of the existing programme.

Agenda item 3: key questions for the review and discussion sources of evidence to answer them

3. Ralph Mold presented a description of each key question being considered by the review.

4. The panel agreed that the review should clearly articulate the aim of the NHS Health Check programme to reduce illness across the population, equitably, by changing the trajectory of the risk-factors for non-communicable disease. A big strength of the programme is that the risk factors it addresses are important for a range of conditions that have a significant impact on the health of the population.

5. The panel agreed that the review should be cautious about recommending the NHS Health Check should do more to address additional risks and conditions before ensuring that the existing programme achieves maximum impact on its main focus of CVD prevention. However, the panel also noted that consideration should be given as to whether there are opportunities to have a significant impact on additional risks and conditions for marginal additional activity in the current NHS Health Check. Mental health and cognitive decline were mentioned as topics where this may be the case. The Lancet Commission on dementia was mentioned as a useful source of evidence on the prevention of cognitive decline.

6. The panel discussed the value of expanding the NHS Health Check to adults younger than 40. It was pointed out that to evaluate the benefit of any change meaningful metrics would need to be identified that could show change in the short and medium-term.

7. A distinction was proposed between pharmacological interventions where costs and benefits accrue simultaneously and behavioural interventions where, after any initial upfront costs, any benefits would be expected to accrue without additional costs to public health or healthcare services. This suggests it is appropriate to consider lifetime risk when recommending behavioural interventions, but that 10-year risk (or similar) should be considered when recommending pharmacological interventions. Concern was expressed that assessing risk in younger age groups could lead to overtreatment with pharmacological interventions. It was suggested that instead of all age groups getting the same NHS Health Check, one option could be for any checks for younger age groups to be more focussed on behavioural change.

8. It was mentioned that CVD guidelines around the world are shifting from focussing on short-term risk to lifetime risk and the panel should consider the implications of this for the NHS Health Check.

9. The panel agreed that the NHS Health Check programme is more likely to be successful in the context of the implementation of wider environment and population-level interventions.

10. The panel discussed the potential for reconsidering the exclusion of people with certain cardiovascular conditions from receiving an NHS Health Check. This was thought to be broadly in line with the current primary care prevention agenda. However, the panel agreed more consideration needs to be given to how the NHS Health Check programme relates to the Quality and Outcomes Framework (QOF) and other initiatives in primary care.

11. The panel discussed the potential value of digital approaches to the NHS Health Check. The panel agreed that this could provide opportunities for more people to engage with the NHS Health Check more easily, allowing people to provide information and receive support for behaviour change. The panel also agreed that there is a risk that digital approaches could increase health inequalities, but that this assumption needs to be tested, particularly given ongoing changes to how people engage with digital channels of communication.

12. The panel noted that there is potential to link to the NHS ‘Empower the person’ programme that aims to improve digital access to health and care information to support people in making health and care choices.

13. The panel agreed that it would be valuable for the NHS Health Check programme to have a quality assurance programme, similar to national screening programmes.

Any other business

14. The next 2 meetings of the group will be on 9 November 2020 and 19 January 2021.

Third meeting: 9 December 2020, 12pm to 2pm, Microsoft Teams

Attendees

Members:

• Professor John Newton, Chair and Director of Health Improvement, PHE
• Dr Shahed Ahmad, National Clinical Director for CVD, NHS England and Improvement
• Professor Clive Ballard, Pro-Chancellor and Executive Dean, College of Medicine and Health, University of Exeter
• Professor Brian Ference, Director of Research in Translational Therapeutics, University of Cambridge
• Professor Carol Jagger, Professor of Epidemiology of Ageing, University of Newcastle
• Professor Tom Marshall, Professor of Public Health and Primary Care, University of Birmingham
• Professor Rosalind Raine, Professor of Health Care Evaluation, UCL Institute of Epidemiology and Health Care
• Dr Robert Sherriff, National Operations Lead, PHE Screening, PHE
• Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity, NHS England and Improvement

Secretariat

• Clare Perkins, Deputy Director, Health Improvement Directorate, PHE
• Ralph Mold, Senior Team Leader, Review of the NHS Health Check Programme, PHE

Apologies:

• Dr Matt Kearney, Director Primary Care Innovation and Deputy Managing Director, UCL Partners, Academic Health Science Network
• Professor Nick Linker, National Clinical Director for Heart Disease, NHS England and Improvement
• Professor Anne Mackie, Director of Screening, PHE
• Professor Dame Theresa Marteau DBE, Director of the Behaviour and Health Research Unit, University of Cambridge

Agenda item 1: minutes of the last meeting

1. The minutes of the last meeting were agreed, subject to amending ‘agreed’ to ‘considered’ in paragraph 13.

2. The amended minutes of the meeting held on the 12 November 2021 were also agreed.

Agenda item 2: review questions, summary evidence so far

3. The panel considered a summary of the evidence gathered for the review to date and discussed the implications of this evidence for potential recommendations.

4. The panel reiterated that the existence and implementation of a broader strategy of wider environmental and regulatory action on the prevention of ill-health is important for successful action on behaviour change.

5. The panel agreed that it was important to engage people from their initial contact with the NHS Health Check all the way through to support for any behaviour change. Increasing the uptake of the programme is valuable if it increases the number of people undertaking appropriate behaviour change.

6. The panel agreed that people should not just be ‘receiving’ NHS Health Checks but participating in them.

7. The panel agreed that it is important to retain what is good about the existing programme, including (a) identifying people for behaviour change interventions; (b) identifying people at high-risk of CVD events for treatment with anti-hypertensives or statins; and (c) identifying people with other conditions (diabetes, atrial fibrillation).

8. The panel discussed the potential value of using digital approaches to engage people with the NHS Health Check, allowing people to provide information and receive support for behaviour change. It was suggested that data already in GP systems could be used to target NHS Health Checks.

9. The panel agreed that there is a risk that digital approaches could increase health inequalities unless there are parallel approaches for people who don’t have access, and the existing evidence on the acceptability and effectiveness of digital approaches need to be considered.

10. The panel discussed the value of other approaches, such as community champions, alongside digital approaches. Digital and non-digital aspects of delivery should be seen as one system and not considered separately.

11. The panel agreed that if digital approaches were to succeed, they would need to be based on the evidence and done well, which would require significant resources.

12. The panel considered the analysis of data from the NHS Health Check programme showing higher rates of attendance, advice and referral to behaviour change for black and ethnic minority groups and more deprived groups, although these peak at the second-most deprived decile. It was noted that this reflects a programme that is already focused on reaching those most at risk and addressing health inequalities.

13. The panel agreed the programme should continue to strengthen its focus on reaching those who would benefit most. It was suggested that the resources provided for the programme could be adjusted so that more resources are directed to the most deprived areas.

14. The panel discussed the potential benefits of the NHS Health Check addressing mental health conditions, such as depression, and musculoskeletal conditions.

15. The panel agreed that any further consideration of whether NHS Health Checks could include additional content to address cognitive decline should focus on addressing risk factors rather than screening for dementia.

16. The panel discussed the question of whether people with a range of existing cardiovascular conditions should continue to be excluded from NHS Health Checks, as at present, or whether these exclusions should be reviewed and potentially removed. It was noted that the QOF incentivises GP practices to maintain registers for patients with these conditions, and that care can be better for conditions with registers, over conditions without registers. However, more information would be needed to advise on an answer to this question.

17. The panel noted that it would be more difficult to exclude people based on a single condition if the NHS Health Check addressed a broader range of conditions in future.

18. The panel discussed the lower age limit for the NHS Health Check, expressing a range of views.

19. The panel agreed that lifetime exposure to risk factors influences future health and that if there were interventions to reduce these risks early in life this would be beneficial. Opinions differed on whether existing evidence indicates that individual-focused interventions to encourage and support behaviour change earlier in life would be effective in substantially improving future health. Studies imply interventions for people that might be at risk may have significant benefits. However, insufficient time has passed for follow-up studies to see what has happened in practice. Any change to the lower age limit of the NHS Health Check would require piloting to understand its impact.

20. The panel agreed that, in general, lifetime risk in younger populations should not be addressed by pharmacological therapy and were concerned there is a risk this could happen. Appropriate evidence-based guidelines should be followed following an NHS Health Check.

21. The panel agreed that wider environmental and regulatory action can improve health across the population and be an effective means of reducing risk in younger populations. Any other business

22. The next 2 meetings of the group will be on 17 December 2020 (a joint meeting with the steering group) and on 19 January 2021.

Fourth meeting: 11 February 2021, 10am to 12pm, Microsoft Teams

Attendees

Members

• Professor John Newton, Chair and Director of Health Improvement, PHE Dr Shahed Ahmad, National Clinical Director for CVD, NHS England and Improvement
• Professor Clive Ballard, Pro-Chancellor and Executive Dean, College of Medicine and Health, University of Exeter
• Professor Brian Ference, Director of Research in Translational Therapeutics, University of Cambridge
• Professor Carol Jagger, Professor of Epidemiology of Ageing, University of Newcastle
• Professor Anne Mackie, Director of Screening, PHE
• Professor Tom Marshall, Professor of Public Health and Primary Care, University of Birmingham
• Professor Rosalind Raine, Professor of Health Care Evaluation, UCL Institute of Epidemiology and Health Care

Secretariat:

• Clare Perkins, Deputy Director, Health Improvement Directorate, PHE
• Ralph Mold, Senior Team Leader, Review of the NHS Health Check Programme, PHE Apologies
• Dr Matt Kearney, Director Primary Care Innovation and Deputy Managing Director, University College London Partners, Academic Health Science Network
• Professor Nick Linker, National Clinical Director for Heart Disease, NHS England and Improvement
• Professor Dame Theresa Marteau DBE, Director of the Behaviour and Health Research Unit, University of Cambridge
• Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity, NHS England

Agenda Item 1: minutes of the last meeting

1. The panel agreed to send a letter to the Chair of the Review with a summary of the Expert Panel’s advice and views.

2. The panel reiterated that the existence and implementation of a broader strategy of wider environmental and regulatory action on the prevention of ill-health is important for successful action on chronic disease with behaviour change being a part of a larger whole. They asked for this to be reflected more prominently in the minutes.

3. The panel agreed the following changes to the minutes:

a. para 9: adding ‘unless there are parallel approaches for people who don’t have access’ following ‘there is a risk that digital approaches could increase health inequalities’. Also adding ‘existing’ before ‘evidence’

b. para 10: adding ‘based on the evidence and’ before ‘done well’

c. para 11: reflecting that rates of attendance, advice and referral to behavior change peak at the second-most deprived decile rather than continuing to rise with deprivation

d. para 12: replace ‘those most at risk and addressing health inequalities’ with ‘those who would benefit most’ e. para 13: replace ‘conditions such as depression’ with ‘mental health conditions such as depression’

f. para 18: insert ‘individual-focused’ before ‘interventions’ in second sentence

g. para 19: add ‘and were concerned there is a risk this could happen. Appropriate evidence-based guidelines should be followed following an NHS Health Check’

4. In discussing para 15, it was noted that while providing NHS Health Checks to those with existing CVD may be beneficial in some circumstances, it would involve being seen twice for similar purposes, so it is uncertain whether the benefit would justify the extra workload.

Agenda item 2: update on progress of the review and expected next steps

5. The panel received an update on the progress of the review. The intention is for the output of the review to be shared with DHSC ministers in time to be considered as part of the government spending review process, which is expected early next financial year. The current plan is to finalise the outputs for sharing with ministers within the next 4 weeks.

6. It was noted that there are many common issues between COVID and CVD – particularly in terms of the risk factors for severe disease and the groups most affected. It was proposed that we will need a focus on CVD as part of efforts to protect those most at risk next winter.

Agenda item 3: recommendations of the review

7. The panel was invited to comment on a set of slides summarizing the draft output of the review.

8. Members were concerned that the summary of the review’s findings gave too positive an impression of the evidence on NHS Health Checks. The most robust scientific evidence does not support the view that general health checks are effective in improving health outcomes.

9. Some members would like the programme to invite only people identified as high-risk, and for the recommendation containing this to be listed first. Members expressed different views on whether it was necessary to gather information additional to that already available through GP patient records to identify those at high-risk.

10. It was suggested by some panel members that if the aim of the programme in future is to assess risk and deliver preventative care based on that risk then it doesn’t make sense to exclude people before fully assessing their risk.

11. Concern was expressed that universal assessment of risk was without evidence as to effectiveness and could lead to unnecessary treatment and other harms, particularly in those known to be at low risk as they are less likely to benefit.

12. The panel agreed that it would be better for the review to use the concept of ‘those most likely to benefit’ instead of ‘those at high-risk’ and ‘those most affected by health inequalities’ as these are 2 different groups (albeit overlapping).

13. The panel agreed that it is essential that the NHS Health Check programme should be the subject of formal ongoing evaluation and research. It was noted that this is the intention of recommendation 6. The panel proposed strengthening the specific actions proposed by the recommendations. It was suggested this could be by recommending that the National Institute for Health Research commit to a large grant for evaluating the NHS Health Check programme.

14. It was noted that evaluation has different purposes, including (a) does something work in principle (b) does it work in practice (c) are we implementing it correctly (d) how to improve quality and uptake? It was suggested the key question for NHS Health Check evaluation is whether it works in practice.

15. The panel agreed that the use of digital approaches (as outlined in recommendation 2) should be conditional on using them in combination with, rather than instead of, other approaches.

16. The panel agreed that recommendation 4 (on the potential for addressing additional conditions) should be amended so that the headline recommendation focuses on assessing the practicality of addressing mental health and musculoskeletal conditions through the NHS Health Check, in line with the sub-recommendations and that reference to the necessity of the UK National Screening Committee recommendations and existing arrangements is made.

17. The panel agreed that recommendation 5 (on lowering the lower age limit for the programme) should be amended so that the headline recommendation focuses on considering the benefits, risks and practicality of lowering the lower age limit for the programme, in line with the sub-recommendations. These considerations should be made before implementing a change given the opportunity costs of lowering the age limit.

18. It was suggested that in addition to the existing draft recommendations the review should highlight the need for the NHS Health Check programme to link with clinical prevention programmes at a local level.

Any other business

19. The panel agreed it should undertake any further work via correspondence in the first instance.

5. Letter to the chair of PHE’s review of the NHS Health Check programme

To: Professor John Deanfield, Chair, PHE’s review of the NHS Health Check programme

Dear John,

Thank you for sharing the draft recommendations of the NHS Health Check review with the Expert Panel (version dated February 2021). We discussed these at our meeting on 11 February 2021 and I offered to write to you with a summary of the feedback from the group. The discussions were also captured in more detail in the minutes of that meeting. We hope that this will be helpful to you as the Steering Group finalises its report.

The Expert Panel recognises the importance of this review and the potential for impact of the programme on population health. We share your enthusiasm for using the experience and evidence of the past to put forward an exciting vision for the future. We are keen therefore to do all we can to help the Steering Group frame its recommendations by providing constructive feedback based on our expertise and specialist knowledge.

The following is a summary of some of the main points of what was a rich discussion. Some points had more consensus for support than others. I have tried to capture, where it is important to do so, the range of views across the group on a given topic. For brevity, I have not included all the points where we were in full agreement with the proposed recommendations.

• the panel believes that the brief summary of the evidence on previous effectiveness over emphasised the positive results. It is a concern of the group for example that many people who receive the health check do not get the follow up interventions they need. Thus, the numbers of people who eventually benefit due to a material change in their risk of diseases at the end of the process is small when considering the large numbers offered the check
• there is a strongly held view among some panel members that the offer should not be a universal one but targeted at those at increased risk, to concentrate the considerable resource on those most likely to benefit. Others on the panel were not as concerned about this issue, but all agreed that as far as possible existing health service data be used to focus the offer thereby avoiding the need for universal attendance for assessment. Thus, hopefully increasing the ability of the programme to achieve high coverage, uptake and adoption of effective interventions to reduce subsequent CVD
• members would like to suggest use of the term “most likely to benefit” as opposed to “at risk”. The former is a more positive statement and includes the existence of an effective intervention in the definition. Simply identifying risk without also offering help and advice has no utility to the person
• the panel would like to see a firm recommendation for an independent, fully funded and comprehensive programme of evaluation of the new NHS Health Check programme. These evaluations should be done within a formal research governance framework (the National Institute for Health Research or sensible alternative) and aim to assess the effectiveness of the end to end pathway (from identification through to outcomes (or good proxies thereof)
• there is support for development of new digital routes for risk assessment and engagement for the NHS Health Check, but panel members would like the review to clarify that digital approaches should be evidence-based, supplemented by other methods so as to maximise the offer and evaluated and monitored for impact on inequalities
• on the 2 key questions of widening scope in terms of additional conditions and younger age there was a range of views. The key would seem to be a clear process of assessing potential benefit through identification and testing of key assumptions, appropriate feasibility testing and evaluation including modelling of potential benefits. The group noted that the new screening advisory body (the updated UK National Screening Committee) is overseen by the UK CMOs and proposed that its advice be formally sought
• there is a strong view that the NHS Health Check programme will be potentially be most effective and efficient if it is closely integrated with other preventive work going on in the NHS especially in primary care, including the management of long-term conditions promoted by the Quality and Outcomes framework, and with national policies to enact wider environmental and regulatory action. Large though it is, the NHS Health Check programme cannot on its own deliver more than a small part of the total preventive activity needed to address the drivers of long-term ill health

The panel looks forward to receiving a draft of the final report for comment.

Best wishes

Professor John Newton, Chair of the Expert Panel of PHE’s review of the NHS Health Check programme